Public reporting of outcomes data might theoretically improve patient outcomes in one of two ways: by redistributing patients between worse and better providers (“name-and-shame”) and by encouraging surgeons with sub-par results to examine their technique and procedures (“continuous quality improvement”). Our view is that continuous quality improvement can be achieved without public reporting of outcomes and that name-and-shame is inherently problematic.
Assume that reported the true recurrence rates of each surgeon. Would it really be advisable to direct patients to the surgeon with the best outcome? It is not at all clear that surgeon 3 could take on an annual caseload of 500 patients, or even 250, if cases were split with surgeon 1. Moreover, given that there are a finite number of hours in the day, other activities of surgeon 3 – such as treatment of other cancers, or research – would need to be redirected back to the surgeons who had lost radical prostatectomy volume. This might lead to an inferior surgeon treating more cases of bladder cancer, which is associated with higher rates of cancer death after surgery, and so could result in a net increase in death rates. Alternatively, surgeon 3’s research, which could potentially help thousands of patients throughout the world, might falter under the increased clinical workload. As such, it is reasonable to question whether changing practice patterns in the light of surgical outcomes data would have done more good than harm.
If our focus becomes continuous quality improvement, then we would argue that public reporting of surgeon outcomes is more of a hindrance than a help. First of all, it is unnecessary. No doubt surgeons need to know their outcomes in order to improve, but there is no reason why these data have to be shared with the public, they can be conveyed to the surgeon privately. Second, public reporting is counter-productive because, as described above, it creates perverse incentives, such as withholding treatment from the patients who have the most to gain. Third, public reporting builds distrust amongst surgeons. If I announce to the world that a particular surgeon has poor outcomes, then that surgeon has every incentive to doubt my data and my methodology. Indeed, that is exactly the experience of the New York cardiology initiative, where fewer than 1 in 6 surgeons believed the published results. If, on the other hand, the information is given confidentially (“these data are provided to you in an effort to help you improve your surgical outcomes; no-one else has access to the data or knows your results”), most surgeons will likely come to realize that ignoring the feedback is not in their own best interest.
Our view is that we would best help our patients were we first to develop reliable systems for continuous quality improvement and only then consider whether public reporting of outcomes would do more good than harm.